Gender dysphoria
Gender dysphoria is a psychological condition characterized by a significant and persistent incongruence between an individual's assigned sex at birth and their identified gender. This condition can manifest through various symptoms, including a strong desire to be recognized as the other gender, discomfort with one's physical sex characteristics, and challenges in social interactions with peers of the same sex. The causes of gender dysphoria are not fully understood but may involve a combination of psychological, biological, familial, and sociocultural factors.
Diagnosis typically occurs in childhood or adulthood, and while many children may outgrow their feelings of gender dysphoria, some individuals experience chronic symptoms into later life. Treatment options include psychological support, hormone replacement therapy, and surgical procedures to align one's physical body with their gender identity. The World Professional Association for Transgender Health (WPATH) provides guidelines for care, emphasizing a respectful, individualized approach to treatment.
Culturally, gender dysphoria has been recognized across various societies and historical contexts. The terminology and understanding of the condition have evolved, reflecting broader discussions about gender identity and societal norms. Recent legal rulings have further influenced the discourse surrounding gender dysphoria, advocating for the rights and healthcare access of transgender individuals while also prompting debate about the implications of classifying gender dysphoria as a disorder.
Gender dysphoria
ANATOMY OR SYSTEM AFFECTED: Genitals, psychic-emotional system
DEFINITION: A psychiatric classification describing persons experiencing a strong and persistent incongruity between their anatomy (their sex) and the gender with which they identify
CAUSES: Psychological, biological, familial, and sociocultural factors
SYMPTOMS: Feeling trapped in a body of the wrong sex, repeatedly stated desire for or insistence on being the other sex (or to being nongendered or a state in between), cross-dressing, difficulty with same-gender peer interaction, disgust toward own genitals or secondary sexual characteristics, psychiatric comorbidity (depression, anxiety, bipolar disorder), behavior problems
DURATION: Diagnosed in childhood or adulthood; can be temporary or chronic
TREATMENTS: Psychological interventions, social interventions, sex reassignment surgery, hormone replacement therapy, voice therapy
Causes and Symptoms
The exact cause of gender dysphoria is not clearly understood or universally agreed upon. Many believe that the condition is not pathological. Others feel that gender dysphoria results from multiple pathways that can work alone or together. These pathways result from an individual’s psychological, sociocultural, biological, and genetic factors and background. Relevant terms in any discussion of gender dysphoria include "sex," which refers to the physical characteristics associated with being either male or female, and "gender," which refers to the culturally defined roles and behaviors associated with a given sex. Concepts related to gender dysphoria include "transsexualism," which refers to people who actively identify with the opposite sex and choose to live as a member of that sex, and "transgender," a catch-all term for people whose gender identity does not match traditional expectations for their sex.
A psychiatrist or psychologist typically makes the diagnosis of gender dysphoria. Diagnostic criteria for both childhood and adult forms have been established by the American Psychological Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders (DSM). ("Gender dysphoria" first appeared in the fifth edition, with a revised edition published in 2022, and represents a renaming of the diagnosis from previous editions, where it appeared as "gender identity disorder.") To carry a diagnosis of childhood gender dysphoria, a child must have an onset of symptoms before puberty. The majority of children resolve their gender dysphoria; others have a continuation of symptoms into adolescence or adulthood. Some people are first diagnosed as adults. Once gender dysphoria is diagnosed in adults, it tends to have a chronic course.
To meet the criteria for diagnosis, an individual must have a cross-gender identification exceeding the desire for perceived cultural advantages of being the other sex. A persistent discomfort with the person's sex or with the of that sex must exist. The disturbance must cause clinically significant distress in important areas of functioning. Gender dysphoria is not necessarily concurrent with disorders of sexual development, a condition in which an individual may be born with ambiguous genitalia (intersexuality). Gender dysphoria is also independent of sexual orientation, occurring in people who identify as both and heterosexual.
Treatment and Therapy
The World Professional Association for Transgender Health (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association) has a set of guidelines established for the standards of care for gender dysphoria. The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People identifies multiple therapeutic approaches to gender dysphoria. These include changes in gender expression and role (cross-dressing and other behavioral changes, either full or part time), hormone replacement therapy (estrogen or testosterone to either feminize or masculinize the body), gender reassignment surgery, and psychotherapy. Therapy should proceed focusing on resolving any comorbid psychological disorders, promoting acceptance, and discussing further treatment options.
Hormone therapy can be given to adolescents to delay puberty. This allows time for an individual to explore gender identity and to make a gender transition more conspicuously. In the United States, or can be given to an individual who is sixteen and who demonstrates knowledge about the benefits and risks, has spent a prescribed period living in the desired role or a period of psychotherapy, and demonstrates readiness.
Sex reassignment surgery is the final step that some people with gender dysphoria choose to pursue. Genital reconstruction can occur in both males and females. An individual who is anatomically female may also desire removal of the breasts, uterus, ovaries, and Fallopian tubes, as well as liposuction and other aesthetic procedures. For someone who is anatomically male, surgery may include breast implants, facial feminization surgery, and vocal surgery.
Perspective and Prospects
Gender dysphoria exists in every culture. It has been recorded as early as Hippocrates, who is credited with the first classification system for what was called Scythian disease. Magnus Hirschfeld coined the term “transvestism” in 1915, describing individuals who cross-dress. In 1949, David Caudwell coined the term “transsexual.” In 1966, Harry Benjamin developed a Sex Orientation Scale to differentiate the various forms of and transsexualism. Since then, there has been extensive debate concerning the correct classification and terminology surrounding gender dysphoria and transgenderism. Many people support the idea that transgender people are leading the way in redefining and updating traditional concepts of gender.
The diagnosis of gender identity disorder was added to the DSM in 1987. The transgender community campaigned for many years, with eventual success, to have this classification changed, as many transgender people found it offensive and incorrect to label gender dysphoria as a disorder. People argue that concepts of gender roles are socially constructed and therefore wonder how a society can define, scientifically, what a “normal” gender identity is. This view has been controversial and again made headlines in August 2022 when a federal appeals court ruling led to additional protections for transgender people under the Americans with Disabilities Act (ADA). The case, filed by a transgender woman who received unfair treatment while incarcerated, initially found that trans people were not covered under the ADA because the act excludes protecting those with "gender identity disorders." According to the ruling judge, "gender dysphoria is not a gender identity disorder." But the appeals court ruled that transgender people should, in fact, be covered under the ADA because "a transgender person's medical needs are just as deserving of treatment and protection as anyone else's," as stated by the appellate judge. Many LGBTQ advocates praised the decision for its inclusion of the trans community and the likelihood that it would help transgender people better access gender-affirming care, though others opposed it because it supported the argument that being transgender is a mental disorder.
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